Capsular distension in high-energy femoral shaft fractures is associated with occult femoral neck fracture: a preliminary retrospective comparative study.

OBJECTIVES: To determine the association between hip capsular distension, the computed tomography (CT) capsular sign, and lipohemarthrosis as they relate to occult femoral neck fracture (FNF) in the setting of ipsilateral femoral shaft fracture (FSF). DESIGN: Retrospective comparative study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Two hundred and forty-two patients with high-energy FSF and no evidence of FNF on preoperative radiographs and pelvis CT. All patients were stabilized with non-reconstruction style nails. INTERVENTION: Pelvis CT scans were examined for hip capsular distension irrespective of the other side, differing side-to-side measurements of capsular distension (i.e., the CT capsular sign), and lipohemarthrosis. MAIN OUTCOME MEASUREMENTS: FNF was observed for on postoperative radiographs. Relative risk (RR), number needed to treat (NNT), sensitivity (SN), and specificity (SP) were determined. RESULTS: Fifty-eight patients (24.0%) had capsular distension. Forty-two patients (17.4%) had differing capsular measurements (i.e., the CT capsular sign), and 16 (6.6%) had symmetrical distension from bilateral hip effusions. Eight patients (3.3%) had lipohemarthrosis. Four FNFs (1.7%) were identified. Three patients had capsular distension, 2 had CT capsular signs, and 1 had lipohemarthrosis. The last patient had no CT abnormalities. Only capsular distension (RR = 10, CI = 1.001-90, P = 0.049; SN = 75%, SP = 77%; NNT = 22) and lipohemarthrosis (RR = 23, CI = 1.6-335, P = 0.022; SN = 50%, SP = 96%; NNT = 8) were associated with occult FNF. CONCLUSIONS: Capsular distension is associated with FNF irrespective of the contralateral hip. Preemptive stabilization using a reconstruction nail could be considered in the setting of capsular distension or lipohemarthrosis to prevent displacement of an occult FNF. LEVEL OF EVIDENCE: Diagnostic Level III.

Preliminary study on the stabilization of varus proximal femoral osteotomies using pediatric LCP plates in adults undergoing combined correction of proximal femoral and acetabular dysplasia.

PURPOSE: Proximal femoral osteotomy (PFO) with periacetabular osteotomy (PAO) improves femoral head coverage in patients with proximal femoral and acetabular dysplasia. Historically, blade plates used in the PFO cause soft-tissue irritation and often lead to implant removal. Here we present a technique using a lower profile pediatric proximal femoral locking compression plate (LCP) for the PFO in a series of adults. METHODS: The results from 13 hips in 11 patients ≥ 18 years old (age 18-37) with > 10 months of follow-up are presented. RESULTS: All patients had improved radiographic parameters, pain, and total Merle d'Aubigné-Postel scores postoperatively. Eleven hips (85%) had the LCP removed an average of 15.8 ± 8.6 months postoperatively, often due to pain over the greater trochanter. CONCLUSION: The pediatric proximal femoral LCP is effective for PFO in combined PAO PFO procedures but has a high rate of lateral hip discomfort leading to implant removal.

Interaction of preoperative chemoprophylaxis and tranexamic acid use does not affect transfusion in acetabular fracture surgery.

PURPOSE: While the effects of tranexamic acid (TXA) use on transfusion rates after acetabular fracture surgery are unclear, previous evidence suggests that holding deep vein thrombosis (DVT) chemoprophylaxis may improve TXA efficacy. This study examines whether holding DVT chemoprophylaxis in patients receiving TXA affects intraoperative and postoperative transfusion rates in acetabular fracture surgery. METHODS: We reviewed electronic medical records (EMR) of 305 patients who underwent open reduction and internal fixation of acetabular fractures (AO/OTA 62) and stratified patients per the following perioperative treatment: (1) no intraoperative TXA (noTXA), (2) intraoperative TXA and no preoperative DVT prophylaxis (opTXA/noDVTP), or (3) intraoperative TXA and preoperative DVT prophylaxis (opTXA/opDVTP). The primary outcomes were need for intraoperative or postoperative transfusion. Risk factors for each primary outcome were assessed using multivariable regression. RESULTS: Intraoperative or postoperative transfusion rates did not significantly differ between opTXA/opDVTP and opTXA/noDVTP groups (46.2% vs. 36%, p = 0.463; 15.4% vs. 28%, p = 0.181). Median units transfused did not differ between groups (2 ± 1 vs. 2 ± 1, p = 0.515; 2 ± 1 vs. 2 ± 0, p = 0.099). There was no association between preoperative DVT chemoprophylaxis and TXA with intraoperative or postoperative transfusions. EBL, preoperative hematocrit, and IV fluids were associated with intraoperative transfusions; age and Charlson Comorbidity Index (CCI) were associated with postoperative transfusions. CONCLUSION: Our findings suggest holding DVT prophylaxis did not alter the effect of TXA on blood loss or need for transfusion.

Limb position affects intraoperative assessment of condylar width.

PURPOSE: We sought to define how changes in position and rotation of fluoroscopic imaging may affect the assessment of condylar widening intraoperatively. METHODS: Thirty-three patients with tibial plateau fractures were prospectively identified and included in this study. Fluoroscopic images of the uninjured tibial plateau were obtained in (1) full extension and (2) slight flexion on foam ramp. Beginning with a plateau view, additional views of the tibial plateau were then obtained by rotating the fluoroscope around the knee in 5 degree increments up to 15 degrees in both internal and external rotation. Measurements of distal femoral condylar width (DFW), distal femoral articular width (FAW), proximal tibial articular width (TAW) and lateral plateau width (LPW) were performed. RESULTS: LPW was decreased in flexion compared to extension at all degrees of rotation (p = 0.04-0.00001). There was a trend toward increasing LPW with increasing degrees of internal rotation which reached significance at 15˚ of internal rotation when the knee was flexed. On ANOVA, there was a significant difference of LPW with increasing degree of internal rotation when the knee was in flexion (p = 0.008), but not in extension. There were no differences in DFW, FAW, TAW and DFW/TAW at any point though LPW was decreased in flexion at all degrees of rotation. The FAW/TAW ratio was increased in flexion at all degrees of rotation. DISCUSSION: The knee in flexion will underestimate the measurement of condylar width compared to the knee in full extension, by ~ 2 mm. Rotation of the knee, in comparison, did not have a significant effect on condylar width assessment. LEVEL OF EVIDENCE: Diagnostic II.

Involved-Field Radiation Therapy for Patients With Unresectable Pancreatic Adenocarcinomas: Failure Pattern Analysis.

Introduction Unresectable pancreatic tumors are frequently diagnosed. Initial treatment is carried out with chemotherapy. Eventually, in selected cases, radiotherapy may be used to improve local control rates and relieve the symptoms. The volume of radiotherapy treatment fields is the subject of controversy in the literature. The use of involved fields with the gross tumor volume encompassing the primary tumor and lymph nodes considered clinically positive is associated with a lower rate of side effects, but can lead to a higher rate of regional loco failures, especially in regional lymph nodes. The purpose of this article is to analyze the failure pattern of chemotherapy and involved-field radiation therapy (IFRT) for treating patients with unresectable pancreatic adenocarcinomas. Methods Clinical records of thirty consecutive patients treated from March 2016 to June 2020 for unresectable pancreatic adenocarcinoma were analyzed. The patients were treated with initial systemic chemotherapy (median: 6 cycles) with regimens based on gemcitabine or oxaliplatin-irinotecan (folfirinox/folfox) followed by radiotherapy (total dose of 50-54 Gy/with fractionation of 2 Gy/day). The patients were treated with IFRT. Local failure (LF) was defined as an increase in radiographic abnormality within the planning target volume (PTV). Elective nodal failure (ENF) was defined as recurrence in any lymph node region outside the PTV. Any other failure was defined as distant failure (DF). Results The median age of the patients was 68 years (range: 44-80 years); 20 patients (66.7%) were men, and 11 (36.6%) and 19 (63.4%) patients presented with tumors of stage II and III, respectively. Most patients (63.3%) had tumors in the pancreatic head. The median survival was 17.2 months. Tumor recurrences were classified as LF, DF, LF and DF in 7 (23.3%), 17 (56.7%), and 5 (16.7%) patients, respectively. Only one patient (3.3%) had both LF and ENF. No severe side effects related to radiotherapy were reported. Conclusion The use of IFRT did not cause a significant amount of ENF, besides presenting low morbidity, which is of special importance for patients with locally advanced tumors or low performance status. The predominant failure pattern was distant metastases.

Olecranon fractures : current treatment concepts.

Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered.Cite this article: Bone Joint J 2023;105-B(2):112-123.

Just-in-Time In Situ Simulation Training as a Preparedness Measure for the Perioperative Care of COVID-19 Patients.

INTRODUCTION: Routine workflows were redesigned during the first surge of the COVID-19 pandemic to standardize perioperative management of patients and minimize the risk of viral exposure and transmission to staff members. Just-in-time (JIT), in situ simulation training was adopted to implement urgent change, the value of which in a public health crisis has not previously been explored. METHODS: Implementation of workflow changes in the setting of the COVID-19 pandemic was accomplished through JIT, in situ simulation training, delivered over a period of 3 weeks to participants from anesthesia, nursing, and surgery, within our healthcare network. The perceived value of this training method was assessed using a postsimulation training survey, composed of Likert scale assessments and free-text responses. The impact on change in practice was assessed by measuring compliance with new COVID-19 workflows for cases of confirmed or suspected COVID-19 managed in the operating room, between March and August 2020. RESULTS: Postsimulation survey responses collected from 110 of 428 participants (25.7%) demonstrated significant positive shifts along the Likert scale on perceived knowledge of new workflow processes, comfort in adopting them in practice and probability that training would have an impact on future practice (all P s < 0.001). Free-text responses reflected appreciation for the training being timely, hands-on, and interprofessional. Compliance with new COVID workflows protocols in practice was 95% (121 of 127 cases) and was associated with lower than expected healthcare worker test positive rates (<1%) within the network during this same period. CONCLUSIONS: These findings support JIT, in situ simulation training as a preparedness measure for the perioperative care of COVID-19 patients and demonstrate the value of this approach during public health crises.

Defining and Addressing Anesthesiology Needs in Simulation-based Medical Education.

Background: This study's primary aim was to determine how training programs use simulation-based medical education (SBME), because SBME is linked to superior clinical performance. Methods: An anonymous 10-question survey was distributed to anesthesiology residency program directors across the United States. The survey aimed to assess where and how SBME takes place, which resources are available, frequency of and barriers to its use, and perceived utility of a dedicated departmental education laboratory. Results: The survey response rate was 30.4% (45/148). SBME typically occurred at shared on-campus laboratories, with residents typically participating in SBME 1 to 4 times per year. Frequently practiced skills included airway management, trauma scenarios, nontechnical skills, and ultrasound techniques (all ≥ 77.8%). Frequently cited logistical barriers to simulation laboratory use included COVID-19 precautions (75.6%), scheduling (57.8%), and lack of trainers (48.9%). Several respondents also acknowledged financial barriers. Most respondents believed a dedicated departmental education laboratory would be a useful or very useful resource (77.8%). Conclusion: SBME is a widely incorporated activity but may be impeded by barriers that our survey helped identify. Barriers can be addressed by departmental education laboratories. We discuss how such laboratories increase capabilities to support structured SBME events and how costs can be offset. Other academic departments may also benefit from establishing such laboratories.

Is the timing of fixation associated with fracture-related infection among tibial plateau fracture patients with compartment syndrome? A multicenter retrospective cohort study of 729 patients.

BACKGROUND: Tibial plateau fractures with an ipsilateral compartment syndrome are a clinical challenge with limited guidance regarding the best time to perform open reduction and internal fixation (ORIF) relative to fasciotomy wound closure. This study aimed to determine if the risk of fracture-related infection (FRI) differs based on the timing of tibial plateau ORIF relative to closure of ipsilateral fasciotomy wounds. METHODS: A retrospective cohort study identified patients with tibial plateau fractures and an ipsilateral compartment syndrome treated with 4-compartment fasciotomy at 22 US trauma centers from 2009 to 2019. The primary outcome measure was FRI requiring operative debridement after ORIF. The ORIF timing relative to fasciotomy closure was categorized as ORIF before, at the same time as, or after fasciotomy closure. Bayesian hierarchical regression models with a neutral prior were used to determine the association between timing of ORIF and infection. The posterior probability of treatment benefit for ORIF was also determined for the three timings of ORIF relative to fasciotomy closure. RESULTS: Of the 729 patients who underwent ORIF of their tibial plateau fracture, 143 (19.6%) subsequently developed a FRI requiring operative treatment. Patients sustaining infections were: 21.0% of those with ORIF before (43 of 205), 15.9% at the same time as (37 of 232), and 21.6% after fasciotomy wound closure (63 of 292). ORIF at the same time as fasciotomy closure demonstrated a 91% probability of being superior to before closure (RR, 0.75; 95% CrI, 0.38 to 1.10). ORIF after fasciotomy closure had a lower likelihood (45%) of a superior outcome than before closure (RR, 1.02; 95% CrI; 0.64 to 1.39). CONCLUSION: Data from this multicenter cohort confirms previous reports of a high FRI risk in patients with a tibial plateau fracture and ipsilateral compartment syndrome. Our results suggest that ORIF at the time of fasciotomy closure has the highest probability of treatment benefit, but that infection was common with all three timings of ORIF in this difficult clinical situation.

Assessing Interrater Reliability of a Faculty-Provided Feedback Rating Instrument.

High quality feedback on resident clinical performance is pivotal to growth and development. Therefore, a reliable means of assessing faculty feedback is necessary. A feedback assessment instrument would also allow for appropriate focus of interventions to improve faculty feedback. We piloted an assessment of the interrater reliability of a seven-item feedback rating instrument on faculty educators trained via a three-workshop frame-of-reference training regimen. The rating instrument's items assessed for the presence or absence of six feedback traits: actionable, behavior focused, detailed, negative feedback, professionalism / communication, and specific; as well as for overall utility of feedback with regard to devising a resident performance improvement plan on an ordinal scale from 1 to 5. Participants completed three cycles consisting of one-hour-long workshops where an instructor led a review of the feedback rating instrument on deidentified feedback comments, followed by participants independently rating a set of 20 deidentified feedback comments, and the study team reviewing the interrater reliability for each feedback rating category to guide future workshops. Comments came from four different anesthesia residency programs in the United States; each set of feedback comments was balanced with respect to utility scores to promote participants' ability to discriminate between high and low utility comments. On the third and final independent rating exercise, participants achieved moderate or greater interrater reliability on all seven rating categories of a feedback rating instrument using Gwet's agreement coefficient 1 for the six feedback traits and using intraclass correlation for utility score. This illustrates that when this instrument is utilized by trained, expert educators, reliable assessments of faculty-provided feedback can be made. This rating instrument, with further validity evidence, has the potential to help programs reliably assess both the quality and utility of their feedback, as well as the impact of any educational interventions designed to improve feedback.

Novel Technique for Percutaneous Reduction of Displaced LCII Pelvic Ring Injury: A Case Report.

CASE: We present a case report of an elderly patient with a displaced lateral compression type II pelvic ring injury and describe a novel technique for maintaining a percutaneously obtained reduction during percutaneous fixation using a supra-acetabular Schantz pin attached to a mechanical limb positioner. CONCLUSION: The mechanical limb positioner used allows the surgeon to hold a multidirectionally obtained reduction of the hemipelvis with ease.

Acetabular labral reconstruction with medial meniscal allograft: preliminary results of a new surgical technique.

PURPOSE: Reconstruction of the acetabular labrum during femoroacetabular impingement (FAI) surgery is accepted when the labrum is deficient and irreparable. Here we describe a novel technique using fresh-frozen medial meniscal allograft for labral reconstruction during surgical hip dislocation for correction of pincer FAI due to acetabular overcoverage. METHODS: The results from seven hips (six patients) that underwent this procedure with 1 year minimum follow-up, and radiographs are presented. RESULTS: Six of the seven hips had improvements in pain, hip flexion, hip abduction, and Merle d'Aubigné-Postel scores. Only one patient with pre-existing osteoarthritis underwent reoperation with conversion to total hip arthroplasty. All digastric trochanteric osteotomies healed, and there were no cases of femoral head osteonecrosis or progression of Tönnis grades. CONCLUSIONS: The medial meniscus is a morphologically and clinically suitable option for labral reconstruction and effectively restores the hip fluid seal.

Indications for cement augmentation in fixation of geriatric intertrochanteric femur fractures: a systematic review of evidence.

INTRODUCTION: Achieving durable mechanical stability in geriatric intertrochanteric proximal femur fractures remains a challenge. Concomitant poor bone quality, unstable fracture patterns, and suboptimal reduction are additional risk factors for early mechanical failure. Cement augmentation of the proximal locking screw or blade is one proposed method to augment implant anchorage. The purpose of this review is to describe the biomechanical and clinical evidence for cement augmentation of geriatric intertrochanteric fractures, and to elaborate indications for cement augmentation. METHODS: The PubMed database was searched for English language studies up to January 2021. Studies that assessed effect of calcium phosphate or methylmethacrylate cement augmentation during open reduction and internal fixation of intertrochanteric fractures were included. Studies with sample size < 5, nontraumatic or periprosthetic fractures, and nonunion or revision surgery were excluded. Study selection adhered to PRISMA criteria. RESULTS: 801 studies were identified, of which 40 met study criteria. 9 studies assessed effect of cement augmentation on fracture displacement. All but one found that cement decreased fracture displacement. 10 studies assessed effect of cement augmentation on total load or cycles to failure. All but one demonstrated that augmented implants increased this variable. Complication rates of cement augmentation during ORIF of intertrochanteric fractures ranged from 0 to 47%, while non-augmented implants ranged from 0 to 51%. Reoperation rates ranged from 0 to 11% in the cement-augmented group and 0 to 11% in the non-augmented group. Fixation failure ranged from 0 to 11% in the cement-augmented group and 0 to 20% in the non-augmented group. Nonunion ranged from 0 to 3.6% in the cement-augmented group and 0 to 34% in the non-augmented group. CONCLUSIONS: Calcium phosphate or PMMA-augmented CMN fixation of IT fractures increased construct stability and improved outcomes in biomechanical and early clinical studies. The findings of these studies suggest an important role for cement augmentation in patient populations at high risk of mechanical failure.

Tranexamic acid does not affect intraoperative blood loss or in-hospital outcomes after acetabular fracture surgery.

PURPOSE: Tranexamic acid (TXA) reduces need for transfusion in total joint arthroplasty, though findings in acetabular surgery are conflicting. We compared outcomes after acetabular fracture surgery with or without perioperative intravenous (IV) TXA administration. METHODS: We performed a retrospective review of 305 patients with acetabular fractures that underwent open reduction and internal fixation (ORIF). Eighty-nine patients received TXA, and 216 did not. The primary outcome was rates of intraoperative and postoperative allogeneic blood transfusion. RESULTS: Baseline demographics and characteristics were similar. Time from injury to surgery and estimated blood loss were comparable. Operative time (p < 0.01) and intraoperative IV fluids (p < 0.01) were greater in the non-TXA group. The proportion of patients who received blood transfusion and mean units transfused intraoperatively and postoperatively did not differ. Mean differences in preoperative and postoperative hemoglobin and hematocrit, hospital length of stay, and perioperative complications also did not differ. In a multivariable regression model, age 60-70 years, Charlson Comorbidity Index, Injury Severity Score, and fracture patterns likely to bleed were independently associated with intraoperative transfusion. Anterior surgical approaches and intraoperative transfusion requirement were independently associated with postoperative transfusion. CONCLUSION: In this study, perioperative IV TXA did not decrease blood loss, need for transfusion, or improve in-hospital outcomes of acetabular fracture surgery. Age 60-70, CCI, ISS, and fracture patterns likely to bleed were independently associated with intraoperative transfusion. Anterior surgical approach and need for intraoperative transfusion were independently associated with postoperative transfusion. Further prospective trials are warranted to confirm these findings.

Impact on periosteal vasculature after dual plating of the distal femur: a cadaveric study.

Although dual plating of distal femur fractures has been described for injuries at risk of varus displacement, the vascular insult to the medial distal femur utilizing this technique is unknown. The aim of this study was to evaluate the perfusion of the medial distal femoral periosteal arteries after supplemental medial plating of the distal femur. METHODS: Fifteen human fresh-frozen cadaveric femora were thawed and randomized to lateral locked plating alone or with supplemental medial plate fixation. Conventional submuscular medial plating was performed using a 12-hole small fragment plate and multiple cortical screws. The superficial femoral artery was injected with latex dye. Specimens were dissected. The patency of the medial distal femoral periosteal vessels was evaluated. RESULTS: Four vessels were consistently observed traversing the distal medial femur: the transverse and descending (d-MMPA) branches of the medial metaphyseal periosteal artery, and the transverse and longitudinal branches of the descending geniculate artery. The anterior longitudinal arch (ALA) was present in 13 of 15 specimens and was fed by the d-MMPA. The median number of periosteal arteries occluded by the medial plate was 2 (6 out of 8 specimens). The d-MMPA was occluded in 6 of 8 medially plated femurs, resulting in a complete lack of perfusion of the ALA. CONCLUSIONS: Submuscular medial plating of the distal femur compressed the d-MMPA in the majority of specimens. This vessel gives rise to the ALA, which lacked perfusion in these specimens. This vascular insult could affect the healing of metaphyseal distal femur fractures treated with dual plating.

Clinical Prognostic Factors for Patients With Esophageal Cancer Treated With Definitive Chemoradiotherapy.

Background Treatment with definitive chemoradiotherapy (CRT) is the best option for patients with locally advanced esophageal tumors considered unresectable or for patients without clinical conditions to undergo surgical treatment. Technological advances in radiotherapy in the last decades have made treatment more accurate with less toxicity, and the association with more effective systemic treatment has been gradually improving survival rates. Aim Evaluate clinical prognostic factors for progression-free survival (PFS) and overall survival (OS) in patients with esophageal cancer treated with definitive radiotherapy (RT) and chemotherapy (ChT). Material and methods The clinical records of 60 patients treated from April 2011 until December 2019 with esophageal cancer considered unresectable and/or without clinical conditions for surgery, treated with definitive CRT, were analyzed. All patients had upper digestive endoscopy (UDE) with positive biopsy, neck, chest, and abdominal CT scan, and 18F-fluorodeoxyglucose positron-emission tomography (PET-CT). Patients were followed with physical examination and CTs every three months in the first and second years and every six months from the third year of follow-up. UDE was made every three to six months after the end of the treatment or in suspicion of tumor recurrence. PET-CT was also performed in the follow-up when clinically necessary. Local and regional failure (LRF) was defined as abnormalities in the image tests within the planning target volume (PTV) and/or positive biopsy on UDE. Any other failure was defined as a distant failure (DF). PFS was defined in the record of the first tumor recurrence site and OS in the death record from the date of the start of treatment. Results The median age of the patients was 66 years (range: 33 to 83 years) and 46 patients (76.7%) were male. Squamous cell carcinoma (SCC) was the most frequent histological type (85%). Most patients had tumors located in the mid-thoracic esophagus (53.3%) and stage III or IV (59.9%). All patients were treated using 3D (76.7%) or intensity-modulated radiotherapy (IMRT; 23.3%). The median total dose was 50.4Gy (41.4-50.4). All patients received platinum-based ChT concomitant with RT. The most common regimen used was carboplatin and paclitaxel, with a median of five cycles. With a median follow-up of 19 months, the median PFS and OS were 10 and 20 months, respectively. LRF and DF as the first site of failure were observed in 22 (36.6%) and 26 (43.3%) patients, respectively. In the univariate analysis, tumor length lower than 2.6 cm, gross tumor volume (GTV) volume lower than 28 cm3, clinical tumor stages T1 and T2, clinical node stage N0, clinical prognostic stage groups I and II, and complete response to treatment, were statistically significant factors for better PFS and OS. In the multivariate analysis, the presence of clinical nodal stage N0 was related to better PFS (p=0.02). Conclusion Node clinical status was the most important clinical factor for PFS. Despite all the technical progress observed in radiotherapy, treatments concomitant with platinum-based chemotherapy are associated with high levels of LRF and DF. New strategies in systemic therapy and radiotherapy are necessary for improving outcomes.

Speckle tracking strain and ECG heterogeneity correlate in transcatheter aortic valve replacement-induced left bundle branch blocks and right ventricular paced rhythms.

OBJECTIVE: Transcatheter aortic valve replacement (TAVR) complications include left bundle branch block (LBBB) and right ventricular paced rhythm (RVP). We hypothesised that changes in electrocardiographic heterogeneity would correlate better with speckle tracking strain measures than with left ventricular ejection fraction (LVEF) on transthoracic echocardiogram (TTE) among patients with TAVR-induced conduction abnormalities. METHODS: We reviewed medical records of 446 consecutive patients who underwent TAVR at our institution. Of the 238 patients with 12-lead electrocardiograms (ECGs) that met our inclusion criteria, 58 had pre-TAVR and post-TAVR TTEs adequate for strain assessment. We compared patients who did not have an LBBB or RVP pre-TAVR and post-TAVR (controls, n=11) with patients who developed LBBBs (n=11) and who required RVPs (n=10) post-TAVR. In our study population (n=32, 41% female, mean age 85.8 years), we evaluated QRS complex duration, R-wave heterogeneity (RWH), T-wave heterogeneity (TWH), LVEF, global longitudinal strain (GLS) and mechanical dispersion (MD). RESULTS: TAVR-induced changes on ECG did not correlate with LVEF. TAVR-induced changes in MD and QRS complex duration correlated among all patients (r=0.4, p=0.04). GLS and RWH correlated among RVP patients (r=0.7, p=0.00003). MD and TWH correlated among LBBB patients (r=0.7, p=0.00004). CONCLUSIONS: In this convenience sample of patients with TAVR-induced conduction abnormalities, RWH and TWH correlated with strain measures but not with LVEF. Strain measures, RWH and TWH may offer additional insights for pre-TAVR evaluation and post-TAVR clinical management.

Evaluating the Use of an Aerosol Box During Simulated Intubations.

To evaluate the use of an aerosol box during video laryngoscopy intubation, we conducted a two-phase simulation-based study to assess if there were significant differences in time needed to safely intubate a patient with an aerosol box in place, as well as assess changes in laryngoscopists' hand motions as determined by changes in accelerometry. 20 anesthesiology providers from our institution participated in the first phase assessing the time to intubation. Use of the aerosol box led to statistically significant increases in intubation times (Wilcoxon-Signed Rank test p < 0.001, z-score = 3.921), with the calculated Pearson's correlation coefficient (r = 0.877) indicating a large effect size. An 8.5 - 11.5 second difference in median intubation times was maintained between corresponding attempts with versus without the aerosol box. 15 participants completed an optional post-assessment survey, with 10 of 15 respondents firmly stating they would not use the box in clinical practice. The hand accelerometry assessment included five anesthesiology providers from our institution. This revealed a statistically significant increase in trials with aerosol boxes for the left hand's general accelerometry with a medium effect size (p = 0.031; z = -1.873; r = -0.484), as well as for the right hand's general accelerometry with a large effect size (p < 0.001; z = -3.351; r = -0.865). Although the aerosol box is an interesting concept, its use is associated with increased time to intubation and a change in ergonomics, which may increase risk during airway management and represents a concern for patient safety.

Supplemental medial small fragment fixation adds stability to distal femur fixation: A biomechanical study.

INTRODUCTION: Bridge plating of distal femur fractures with lateral locking plates is susceptible to varus collapse, fixation failure, and nonunion. While medial and lateral dual plating has been described in clinical series, the biomechanical effects of dual plating of distal femur fractures have yet to be clearly defined. The purpose of this study was to compare dual plating to lateral locked bridge plating alone in a cadaveric distal femur gap osteotomy model. MATERIALS AND METHODS: Gap osteotomies were created in eight matched pairs of cadaveric female distal femurs (average age: 64 yrs (standard deviation ± 4.4 yrs); age range: 57-68 yrs;) to simulate comminuted extraarticular distal femur fractures (AO/OTA 33A). Eight femurs underwent fixation with lateral locked plates alone and were matched with eight femurs treated with dual plating: lateral locked plates with supplemental medial small fragment non-locking fixation. Mechanical testing was performed on an ElectroPuls E10000 materials testing system using a 10 kN/100 Nm biaxial load cell. Specimens were subject to 25,000 cycles of cyclic loading from 100-1000 N at 2 Hz. RESULTS: Two (2/8) specimens in the lateral only group failed catastrophically prior to completion of testing. All dual plated specimens survived the testing regimen. Dual plated specimens demonstrated significantly less coronal plane displacement (median 0.2 degrees, interquartile range [IQR], 0.0-0.5 degrees) compared to 2.0 degrees (IQR 1.9-3.3, p = 0.02) in the lateral plate only group. Dual plated specimens demonstrated greater bending stiffness compared to the lateral plated group (median 29.0 kN/degree, IQR 1.5-68.2 kN/degree vs median 0.50 kN/degree, IQR 0.23-2.28 kN/degree, p = 0.03). CONCLUSION: Contemporary fixation methods with a distal femur fractures are susceptible to mechanical failure and nonunion with lateral plates alone. Dual plate fixation in a cadaveric model of distal femur fractures underwent significantly less displacement under simulated weight bearing conditions and demonstrated greater stiffness than lateral plating alone. Given the significant clinical failure rates of lateral bridge plating in distal femur fractures, supplemental fixation should be considered, and dual plating of distal femurs augments mechanical stability in a clinically relevant magnitude.

Hypotensive Anesthesia does not reduce Transfusion Rates during and after Acetabular Fracture Surgery.

BACKGROUND: Acetabular fracture open reduction and internal fixation (ORIF) is generally associated with high intraoperative blood loss. Hypotensive anesthesia has been shown to decrease blood loss and intraoperative transfusion in total joint arthroplasty and posterior spinal fusion. In this study, we assessed the effect of reduction in intraoperative mean arterial pressures (MAPs) during acetabular fracture surgery on intraoperative blood loss and need for transfusion. METHODS: Three hundred and one patients with acetabular fractures who underwent ORIF at an academic Level 1 trauma center were retrospectively reviewed. Patients were separated based on mean intraoperative MAPs (<60 mmHg, 60-70 mmHg, >70 mmHg). Thirteen patients had mean intraoperative MAP <60 mmHg, 95 had MAP 60-70 mmHg, and 193 had MAP >70 mmHg. Rates of intraoperative and postoperative allogeneic blood transfusion were compared. RESULTS: Mean intraoperative MAPs were significantly different between groups (p < 0.0001). Time from injury to surgery, estimated blood loss, operative time and intraoperative IV fluids were comparable. The proportion of patients who received blood transfusion and mean units transfused intraoperatively and postoperatively were similar between groups. Mean differences in preoperative and postoperative hemoglobin and hematocrit were also similar. There was no difference in hospital length of stay or perioperative complications between the groups. Multivariate logistic regression analysis demonstrated that body mass index > 30 (p < 0.05) and anterior surgical approach (p < 0.01) were independently associated with intraoperative transfusion and an anterior surgical approach (p < 0.001) was independently associated with postoperative transfusion. CONCLUSION: Decreased intraoperative MAP during acetabular fracture surgery does not reduce blood loss or need for transfusion. On the other hand, no increased end-organ ischemia was seen with hypotensive anesthesia. LEVEL OF EVIDENCE: Therapeutic Level III.